By Robin L. Flanigan –  January 28, 2019

Three years ago, before the community health center His Branches partnered with Common Ground Health, this was a typical scenario:

Moments into a patient’s visit, Medical Director Dr. Matthew Mack would realize he didn’t have the MRI results he needed. He’d then dart to the front of the office to find out where they were. A secretary would search for, and ultimately find, them—just in time for the patient’s visit to end.

“There was zero foresight and the stress level was much higher,” he recalls.

The center’s two locations, in the 19th Ward and Beechwood neighborhoods, experienced similar challenges.

From left, Jenai Lawton, medical assistant, Regina Gonzalez, patient advocate, Dorcas N. Green, registered nurse, Sue Swift, quality improvement advisor with Common Ground Health, and Dr. Matthew Mack, M.D., meet in a huddle at His Branches medical center on Jan. 17, 2019.

“It was planned chaos all day long and across the board,” says Sue Swift, who serves as a quality improvement advisor on Common Ground’s practice transformation team. She worked with staff at both locations on providing comprehensive care before, during and after patient visits.

“It sounds simple,” Swift adds, “but it’s transformative for practices and for patients.”

His Branches’ relationship with Swift as a consultant introduced critical strategies and skills to the safety net practice. As a result, the center reduced wait times, stretched follow-up visits from 15 to 20 minutes, improved patient outcomes, and implemented a host of other care enhancements.

Those quality improvements recently helped His Branches earn renewal as a New York Patient-Centered Medical Home, recognition that the practice is using a holistic, patient-centered approach and is committed to continuous improvement. Research shows that practices using the medical home model benefit from lower health care costs, improved patient experience and better health outcomes.

“Sue was firm and gentle, the perfect combination for a leader,” says Dr. Mack. “We’re a grassroots kind of place and there were times we felt overwhelmed and discombobulated with so many details, but she helped us stay grounded.”

Using metrics to track its entire patient population, rather than only focusing on those who show up for appointments, the center has a much broader perspective and greater ability to close gaps in care. It can, for example, see which patients have not shown up for immunizations or lead screenings, or how many with hypertension and diabetes are overdue for a follow-up visit. Staff can then reach out to these individuals, helping to catch medical issues when they are easier and cheaper to treat.

Jenai Lawton, medical assistant and Regina Gonzalez, patient advocate, talk about care they will provide during the day during a meeting at His Branches Medical Center. Common Ground Health assisted His Branches with putting in place team-based care.

Perhaps the biggest impact has come from establishing care teams, each one comprised of a provider, a nurse, and a patient advocate. The teams meet 30 minutes before the first patient appointment to plan out the day with intention. These huddles ease tension for staff and for patients—the majority of whom are uninsured, qualify for Medicaid, or are otherwise vulnerable—especially when emergencies arise.

The care teams also meet every two weeks to improve the way they work together. Staff members take turns leading the meetings to build leadership skills and rapport.

“Communicating up front makes sense,” says Jennifer Wolford, RN, nurse manager. “We’re just more organized and have a better understanding of a patient’s needs before they come in the door.”

Patients have picked up on the care team structure.

“I am noticing an increase in the number of times I hear ‘She’s my nurse,’” notes Wolford. Patients “are recognizing which nurse works with which provider, and they know specifically who they want to talk with. That builds trust over time.”

As patient problems become more complex, it’s important for practices to develop a mindset of continuous improvement. To that end, different project teams meet on a regular basis to discuss outcome measures, patient-centered metrics, and other topics, and the center is initiating focus groups to learn more about what can be done to improve satisfaction and compliance rates.

In the meantime, the center maintains its own focus on moving toward a value-based payment model, which rewards health care providers for improving health outcomes—not only for performing procedures.

Before the center’s partnership with Common Ground, approximately 90 of its income was a fee-for-service payment model. That dropped to 65 percent during the last fiscal year, reflecting the increased rewards to the practice has earned by improving patient populations outcomes.

“We’re shifting that balance very deliberately and happily,” says Dr. Mack. “Not to be prideful about it, but we’ve worked hard to better focus on value-based payment measures. We are really embracing the concept, and want to be a bigger part of the conversation.”

Annual Banquet

November 2nd, 6-8 pm

at Shadow Lake

GNOC is our partner in ministry on Rochester’s Northeast Side where our Joy Family Medicine office is located.

Help us support our brothers and sisters!

shows how Rochester churches have inspired members to eat healthier, get active and lower their blood pressure. The three-minute story follows the work of the Interdenominational Health Ministry Coalition, a group of volunteer health champions who partner with the High Blood Pressure Collaborative in more than 20 churches.

Produced for the Collaborative’s Urban Wellness Summit at the Maplewood YMCA held on September 29,  the video includes participants sharing their motivations for lifestyle change, like this father’s love for his two-year old son: “I want to make sure that I’m around to see him grow up.”

Check out this summer’s edition of the CCHF newsletter, just out August 26, for a cameo appearance of our ministry!

Six of us attended the annual CCHF Conference this year in Oklahoma City and were energized by the fellowship, teaching, and worship we experienced together. For over 30 years CCHF has been an inspiration to us and centers serving the underprivileged like ours around the country. It’s an honor to have them standing with us in prayer and support for the future of our ministry.

Read the newsletter in flipbook format above, or download a PDF version.

by our dedicated Federally Qualified Health Center (FQHC) application team, led by Stephanie Smith with expert assistance from Jan Thirlby, Deb Blanchard, Valerie, Norm, Josh Moody, and many more staff and Board members, we’ve finally succeeded in submitting our full application for FQHC New Access Point (NAP) designation!

This was truly the “heavy lift” we had anticipated, and even more! The huge page Phase 2 application, which was due on July 15, had our teams meeting daily as we drew closer to the deadline and nearly overnight for the last two days. We strengthened our Board by adding 3 new members, added final tweaks to our Policies & Procedures Manual, solicited and received over 2 dozen very encouraging letters of support from churches, community groups, health care organizations, and governmental officials, wrote reams of analysis, planning, and implementation narrative, and gathered information about budget, position descriptions, and staff biographical sketches.

Please pray for the HRSA reviewers as they consider our full NAP application in the weeks ahead and for our team as they regather later in this year to revisit the materials we’ve submitted and reshape them into a backup FQHC “Look-Alike” application for submission.

We’re on our way back from a wonderful gathering of dedicated health professionals meeting in Oklahoma City for the annual 3-day conference of the Christian Community Health Fellowship, focusing on the theme of “Reconciliation.”

This year we were able to send six of our staff members to be edified by times of prayer and fellowship, worship and sharing the Word, inspired messages and invigorating workshops, and (yes) some just plain fun.

Click here to read more about HBHS and the relationship we have with CCHF.

Drs. Morehouse and Mack with Valerie, Gloria, Michelle, and Susan

And don’t forget to ask any of us about what we saw, heard, and learned the next time you see us!

to join us in making 2016 an even better year for all of us in our personal health and in our relationships with our families, friends, neighbors, and co-workers, as well as in learning how to live meaningful lives of service to those around us! His Branches Health Services is looking forward to continued growth, and we’re counting on your support and prayer along the way as we:

• work more closely together as teams to meet your needs.
• grow our Patient Centered Medical Home and make it even more “home-like.”
• learn more about the advanced capabilities of our new Medent EMR system.
• expand our national certifications beyond Meaningful Use and PCMH to FQHC status.
• recruit another physician to join our staff who likes to deliver babies.
• understand more about applying living faith in all that we do.

God bless you all!

As some of you may know, His Branches Health Services (HBHS) is a Community Health Center (also called a “Diagnostic & Treatment Center” or “D&TC”) licensed by New York State to provide quality care to underserved individuals and families in Rochester. This designation enables our Board of Directors to oversee not only the character of the care we provide but its quality as well.

Along with carrying out a number of quality assurance initiatives, including those mandated by ongoing Meaningful Use, Patient Centered Medical Home, and Accountable Health Partners certification, we are seriously beginning to look at what is involved in going beyond being what could be called a “State Qualified Health Center” to become a “Federally Qualified Health Center” or “FQHC.” We’ve been going over the application process and find that becoming licensed by NY State has almost gotten us there, but it’s still another stretch and a piece of work not only to put together but to maintain.

The end result would represent a further improvement in the patient care data analysis we do as part of our quality assurance activities and would enhance our reimbursement formula, allowing us to serve the community better. Click here if you’d like to find out more or help us along the way!

In addition, our close collaboration with Embracing Options and other pregnancy care centers in the area continues to offer us rich opportunities to provide medical and maternity care for many of their clients. In keeping with our commitment to serve the whole person – body, soul and spirit – we offer to close all of our patient encounters with prayer asking the Lord for wisdom, healing and help. We are so thankful for the privilege of co-laboring with a God who hears and answers when we call.

Please pray for us as we learn better ways to connect with and love our neighbors as Christ would have us do in today’s complex world.

After months of planning and extensive preparation, we’re on the verge of converting over from the Electronic Health Record (EHR) that we’ve been using for the past 10+ years to a more robust system called Medent. The decision to change was made last spring after months of prayer and research into our future needs for a more sophisticated system to handle the increasing patient care requirements of our Patient Centered Medical Home as well as the complexities of clinic billing. For the past 7 months we’ve been working extensively behind the scenes with both our current vendor and Medent to prepare 10 years of patient care data so that it can be transferred without loss to our new EHR.

Everyone on our staff has been undergoing training this month, and a cut-over time has been set: our last full clinical day using our current system will be this coming Thursday, January 29; 10 years of patient records will be downloaded and exported to Medent on Friday, January 30 and over the weekend; Medent will be up and running on all our computers on Monday, February 2 so we can set up our schedules and test it out to make sure everything is operating; and on Tuesday, February 3 we will “go live” and get back into the swing of patient care on Medent. It’s going to be a learning curve for all of us, so please pray for us and be patient!

Special thanks go out to our neighbor and brother in the faith Gary Passero, who has been faithfully donating his time and expertise to tailoring our “export” process so that our data can be seamlessly “ingested” into Medent at the time of cut-over. We’re also deeply grateful for the support we’ve received from our current vendor and the staff at Medent during this time of preparation. And it’s our privilege to report that, by God’s grace, the costs of our transition have been almost completely underwritten by a substantial grant from the University of Rochester Medical Center and support from our CMMI grant and generous donors!